=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184254609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN JUAN DENTAL HYGIENE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2020
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 226 S NEVADA AVE
-----------------------------------------------------
City | MONTROSE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81401-4234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-760-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 178 VALLEY VIEW RD
-----------------------------------------------------
City | RIDGWAY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81432-9322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTAL HYGIENIST
-----------------------------------------------------
Name | SHANNON NEIL
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 405-760-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------